The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

Novel coronavirus 2019 is a single-stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non-technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.

Transoral robotic surgery (TORS): a new tool for high risk tracheostomy decannulation

Tracheostomy decannulation has always been considered a procedure with an attendant risk, especially in patients with a reduced upper airway diameter as is commonly observed in the obstructive sleep apnoea (OSA) population. We report on 4 cases where transoral robotic surgery (TORS) helped in the management of long-term cannulated patients. The aims of our paper are: 1. To demonstrate how the otolaryngology team can help identify patients at high risk for decannulation failure; and 2. To demonstrate how TORS may aid in the decannulation process of patients at high risk for failure due to severe tongue base hypertrophy. From our experience, TORS appears to offer an effective option to aid in the decannulation of patients with a severe hypertrophy of the base of tongue and floppy epiglottis.

Clinical utility of preoperative screening with STOP-Bang questionnaire in elective surgery

BACKGROUND

Obstructive sleep apnea (OSA) is a common disease which increases the risk of perioperative complications. The aim of this study is to assess the clinical utility of preoperative screening for OSA in determining the prevalence of patients at high risk of OSA in a surgical population, the incidence of difficult airway management and the incidence of perioperative complications.

METHODS

We conducted a multisite, prospective observational study on adult patients scheduled for elective surgery. All patients completed a STOP-Bang questionnaire as a part of their preoperative evaluation. Collected data included: demographic data, type of surgery, ASA class, postoperative course, complications within 48 hours, difficult intubation (DI) and difficult mask ventilation (DMV) rates.

RESULTS

A total of 3452 consecutive patients were recruited; 2997 (87%) were identified as low OSA risk patients and 455 (13%) were identified as high OSA risk patients; 113 (3%) postoperative complications, 315 (9%) cases of DMV and 375 (11%) of DI were observed. The percentage of postoperative complications in patients with HR-OSA was 9%, while the percentage of DI was 20% and the percentage of DMV was 23%. High risk for OSA and higher BMI (≥30 Kg m-2) were independently associated with risk for perioperative complications.

CONCLUSION

In conclusion, this study demonstrates that the prevalence of high OSA risk patients in the surgical population is high. The increase in the rates of perioperative complications justifies the implementation of perioperative strategies that use the STOP-Bang as a tool for triage.

Diagnostic role of rapid on-site cytologic examination (ROSE) of broncho-alveolar lavage in ALI/ARDS

BACKGROUND

While bronchoscopy should be considered in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in which the cause cannot be determined from history or clinical and laboratory data, there are no studies about the utility of rapid on-site examination (ROSE) of broncho-alveolar lavage for identification, as early as possible, of the pathological condition underlying the onset of this condition. The aim of this prospective, observational study was to evaluate the diagnostic role of ROSE of BAL in ALI/ARDS.

METHODS

71 patients with ALI/ARDS underwent bronchoalveolar lavage, and one part of the sample was examined with ROSE. The on-site report was categorized as diagnostic (specific diagnosis), presence of atypical reactive type II pneumocytes with no further comments or not diagnostic.

RESULTS

ROSE of bronco-alveolar lavage yielded 29 (41%) specific diagnoses, revealed typical features of diffuse alveolar damage without a specific diagnosis in 28 patients (39%) and did not reveal a specific diagnosis in the remaining 14 cases (20%).

CONCLUSIONS

The results of this study show that, in patients with ALI/ARDS, bronchoalveolar lavage with ROSE is diagnostic in 40% of cases: ROSE may therefore spare lung biopsies and improve the prognosis of patients with ARDS (immunocompetent or not) as therapy could be started or modified at a very early phase.

Analgesia for thoracic surgery: the role of paravertebral block

An appropriate post operative analgesia after thoracotomies is mandatory to improve the patient's outcome, reduce complications rate, morbidity, hospital cost and length of stay. In this paper we review the evidences regarding the use of paravertebral block for thoracic surgery. In particular we examine the effect of paravertebral block compared to the other technique in four major issues: analgesia, complications rate, postoperative pulmonary function and transition from acute to chronic pain. We conclude that paravertebral block is superior to intravenous analgesia in providing pain control and preserving postoperative pulmonary function while it is equal to thoracic epidural analgesia regarding this two issues. Paravertebral block has a better safety profile when compared to intravenous and thoracic epidural analgesia. Its effect on chronic pain incidence still needs further studies.

Left diaphragmatic hernia after pneumonectomy

Patients undergoing pneumonectomy can suffer by cardiovascular and respiratory postoperative complications that can affect patient's outcome by increasing morbidity and mortality. We describe a diaphragmatic hernia occurring after pneumonectomy. with late presentation and with epidural analgesia confusing the scenario suggesting that anesthesiologists should remain aware on this complication even in the late post operative period.

Airway management in an infant with congenital centrofacial dysgenesia

The use of a laryngeal mask airway (LMA) on two occasions, in a 53-day-old and 270-day-old male infant with Tessier N.3 and N.4 facial defects, using sedation and topical anaesthesia is described. The LMA was used to manage the airway and facilitate inhalation induction of anaesthesia as the facial deformities were thought to be too extensive for the safe use of a facemask. The LMA is an alternative to a facemask and secures the airway and facilitates the inhalation induction of anaesthesia in paediatric patients with severe facial deformities.